Discussion:
In recent years, sialendoscopy has demonstrated effectiveness in
avoiding sialoadenectomy, and therefore external approaches, in selected
cases of obstructive and non neoplastic
pathology3.
In many of these cases, and in case of bulky intraductal palpable stones
in the floor of mouth, the same results are obtained by transoral
incision and removal.
However, in many cases of neoplastic pathology and chronic sialadenitis,
sialoadenectomy remains indicated. With the advent of minimally invasive
techniques, there has been a renewed interest in developing approaches
that avoid visible scars, including robotic-assisted
trans-hairline/retroauricular approaches (DOI:
10.1016/j.ijom.2012.04.008) and transoral robotic surgery
(TORS)4.
Yet, the “classical” transcervical approach remains the most validated
and popular among head and neck surgeons, and the less demanding in
terms of time and technology required. The submandibular degloving,
always performed in the present
series1,
is a variant of the classical transcervical approach.
In table II results and complication rate among different
sialoadenectomy techniques in different series are compared.
In the present series, the most relevant complication was the
postoperative bleeding in a patient with a large (4.5 cm) benign tumor
(pleomorphic adenoma); such large dimensions may be a contraindication
to the described technique.
Another complication has been a surgical bed hematoma after the removal
of the suction drain, associated with uncontrolled hypertension on the
6th postoperative day; it required the placement of a new suction drain
and the adjustment of antihypertensive therapy, and confirmed our
attitude, differently from some recent
reports5,
to always use suction drains to reduce the risk of postoperative
haemorrhage and infection.
Benign tumours do not disrupt the capsular layer of the gland so that if
the technique is carried out correctly the risk of spillage is supposed
to be minimal. This assumption is confirmed by the fact that in the
present series we recorded no recurrences among the benign tumors
resected.
However, in the literature, the most relevant risk in submandibular
gland surgery is the damage to the nerves lying in the area. The
Hayes-Martin maneuver is the most adopted trick to spare the MMN. On the
other hand, the main arguments of the advocates of the intraoral
approach are that it avoids the cervical incision and, most of all, the
dissection in close proximity to MMN itself. However, such approaches
are associated with a higher risk of lingual and hypoglossal nerves
injury and limitation in tongue
movements6–89(see
table II). In addition, intraoral dissection is difficult in chronically
inflamed glands with severe adhesions to surrounding tissue, and
conversion to the transcervical approach may be
necessary8.
Because of such a markedly higher overall rate of nerve injury in
transoral approaches, the transcervical approach remains the standard
for submandibular sialoadenectomy. The present work is the first series
of submandibular deglovings in the literature showing a neural
complication rate (only two cases of transient nerve dysfunction in the
present series) lower than the classical submandibular sialoadenectomy
operation7,10–17.
Such preliminary results, if confirmed on larger series, would support
submandibular degloving, based on blunt subfascial and supracapsular
dissection, sparing of the fascial layer and of vessels and nerves
within it1, as a
new standard for submandibular sialoadenectomy.